The medical malpractice suit involving a Pennsylvania man emphasizes that errors can occur at any stage of the medication process—from prescribing to dispensing and administering.
The patient was administered a paralyzing agent by mistake, resulting in catastrophic side effects.
In September 2021, Didier Epopa, now 55, of Delaware County, PA, was being treated for COVID-19 at Philadelphia’s Mercy Fitzgerald Hospital. On the afternoon of September 25, a nurse hooked up a bag labeled Remdesivir to Epopa’s IV. Epopa had already received four doses of Remdesivir and was set to be released after this fifth dose.
However, the bag had been mislabeled. Instead of Remdesivir, Epopa received a dose of the muscle-paralyzing agent cisatracurium. When a nurse returned to check on Epopa, he was experiencing seizures. Epopa’s heart had stopped. A “Code Blue” was called, and medical staff resuscitated Epopa about 11 minutes later. Epopa was intubated and moved to the ICU.
Recalling the event, Epopa, who was educated as a lawyer in his home country of Cameroon, said that he felt his body seize up and his muscles stop responding. He was unable to use his call button or open his mouth to call for help. He reported feeling as if he were being buried alive.
Due to pandemic precautions, neither Epopa’s wife, Edwige Tsafack, nor his teenage daughter were with him when his heart stopped. In fact, based on earlier conversations about Epopa’s progress, Tsafack was planning to bring him home later that day. Instead, when she called Mercy Fitzgerald Hospital on her way to work, she learned that her husband was in critical condition. A doctor notified Tsafack that Epopa had suffered an anoxic brain injury, respiratory failure with hypoxia, and liver shock.
Epopa remained in the hospital for over a month. Progress was minimal. During this time, doctors reportedly told Tsafack that it was unclear why Epopa’s heart had stopped. Then, in late October 2021, the leftover liquid from Epopa’s September 25 IV bag was tested, leading to the discovery of the critical error. Medical records show that Tsafack was informed of the error on October 27, 2021. Disclosing known medical errors to patients is required by Pennsylvania state law.
On November 3, 2021, Epopa was transferred to Kindred Hospital, a long-term care facility. He was still using a ventilator when he was admitted and remained on it for over two weeks until the staff successfully weaned him off of it. Epopa did not return home for another four months. He required extensive therapy to relearn how to talk and perform other daily tasks. He developed multiple bacterial infections and diabetes during his hospitalization. Once an avid runner and biker, Epopa now requires assistance for many physical tasks. He is unable, for example, to hold a pen or spoon steady.
The state of Pennsylvania, Mercy Fitzgerald Hospital, Trinity Health Mid-Atlantic, and Mercy Fitzgerald’s parent healthcare organization all have rules in place to prevent medication errors such as the one Epopa experienced. Records show that many of these regulations were followed. The nurse who administered Epopa’s medication checked the prescription, scanned the medication label on the IV bag, and then took steps to confirm Epopa’s identity before hooking up the IV bag.
However, the bag had been mislabeled by a pharmacy intern. Reportedly, the intern still has active pharmacy intern certification, and no action has been taken against their license. It’s unclear if the state Board of Pharmacy is aware of the error. Under state law, Epopa’s case would have triggered a serious incident report to the Pennsylvania Department of Health; however, the state chose not to conduct an on-site investigation at Mercy Fitzgerald following the incident.
Recently, Epopa and Tsafack filed a malpractice lawsuit against Trinity Health Mid-Atlantic and three other Philadelphia-area hospitals. The suit names the pharmacy intern and the supervising pharmacist on shift. Trinity Health Mid-Atlantic has not commented on the suit.
Medication errors and liability
It’s estimated that between 7,000 and 9,000 people in the United States die as a result of medication errors each year.
Costs associated with caring for patients with medication-associated injuries exceed $40 billion each year. In a hospital setting, medication orders start with a prescribing doctor and then go through a dispensing pharmacist and administering nurse before reaching a patient. An error can occur at any step along the way, and any of the professionals involved can be found liable.
Typically, it’s ruled that explaining the medication and any possible side effects and interactions is the physician's responsibility and that preventing wrong dosages is the pharmacist's responsibility. In some cases, suits are brought against pharmacists and physicians, determining where liability rests left to a jury.
A 2021 study published in Clinical Practice and Cases in Emergency Medicine examined four key cases involving medication errors, physicians, and pharmacists and found clear patterns. The authors wrote:
[S]tate courts have agreed that it is the physician’s duty to warn of these potential side effects…Simply placing warning labels on medication bottles does not imply that a pharmacist is accepting shared liability for a physician’s duty to warn…Pharmacists, on the other hand, have a duty to safely fill prescriptions and can be held liable for adverse outcomes if a prescription that a reasonable pharmacist would deem to be unsafe is still filled and dispensed.